Author: Richard Evan Steele (Klinikken Livet, Silkeborg, Denmark)

Series: Health and Human Development

Truths are never lost, they are just occasionally forgotten. Rick Steele’s reflections on managed (primary) care are a powerful testimony to this.

In an age of ever-increasing hyperspecialisation in biomedical and clinical practice, of virtually logarithmic doubling of peer-reviewed health science literature every year, and of ever-stronger beliefs around the pervasive nature of evidence-based health care, we have forgotten an important truth about people’s health and how to care for it. Health is hardly created by the health system, which should rather be called the palliative system, or disease management system. Health, as the recent Marmot reviews on their social determinants show, is created where people live, love, work and play. Those places (or ‘settings for health’) are created and sustained by powerful systemic parameters, such as the economy, the ecosystem, education and early life, and most of all, political choice.

Managing this complex, interconnected system of causes and ’causes of causes’ of health and illness cannot be left to epidemiologists or clinicians, however brilliant they are.

Steele argues for a comprehensive, targeted and multiprofessional approach to managed primary care that deals with some of the most challenging issues in the disease management system. His analysis stems from work mainly carried out in the 1980s and 1990s, and is strongly validated for the new millennium by two streams of action. First of all, Steele himself has been practicing his approach in a variety of capacities in Scandinavia for some decades now, yielding impressive results. But more importantly, recent insights and rediscoveries by WHO and other international and national bodies substantiate Steele’s proposals. Recently, the World Health Assembly re-endorsed the Primary Health Care approach unequivocally, and not as a partial ‘horizontal’ or partial ‘vertical’ disease-driven community development strategy. Even more recently than that, a United Nations Summit was convened to address the looming, and in many places already rampant, epidemic of non-communicable disease. On both occasions, a measured and managed approach to health development and disease prevention was strongly advocated, and in turn endorsed by civil society.

Rick Steele isn’t just rediscovering these truths. In his work he shows how to make them work.